advocacy, communication, and social mobilization to fight xdr tb wanda walton, phd, med...
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Advocacy, Communication, and Social Mobilization
to Fight XDR TB
Wanda Walton, PhD, MEdCommunications, Education, and Behavioral Studies Branch
Division of Tuberculosis Elimination
ACSM to Address Key Challenges to TB Control at Country Level
• Improving case detection and treatment adherence
• Combating stigma and discrimination
• Empowering people affected by TB
• Mobilizing political commitment and resources for TB
Framework for ACSM to Address Key Challenges to TB Control
at Country Level• Building national and subnational ACSM capacity
• Building inclusion of patients and affected communities
• Ensuring political commitment and accountability
• Building country-level ACSM partnerships
• Learning, adapting, and building on good ACSM practice
Advocacy, Communication, and Social Mobilization for XDR TB • Communication to exchange information about XDR
TB, informing and creating awareness
• Advocacy to place XDR TB control high on the political agenda, foster political will, increase financial and other resources, e.g., human resources
• Social mobilization to bring together allies to raise awareness and demand for program needs, assist in delivery of resources and services, create sustainable change
XDR TB Extensive (or Extreme) Drug Resistant TB
XDR TB extensive (or extreme) drug resistant TB• MDR TB - defined as TB resistant to at least the 2
most potent anti-TB drugs, isoniazid and rifampicin (first-line drugs)
• XDR TB* - defined as MDR TB that is also resistant to at least 3 of the 6 classes of second-line drugs
*Definition may change based upon recommendations of expert panel
Drugs for the Treatment of TB
1. Isoniazid
2. Rifampicin
3. Pyrazinamide
4. Ethambutol
5. Aminoglycosides
6. Capreomycin
7. Quinolones
8. Thioamides
9. Cycloserine
10. PAS
First-line drugs and treatment of drug-susceptible TB
1. Isoniazid
2. Rifampicin
3. Pyrazinamide
4. Ethambutol
5. Aminoglycosides
6. Capreomycin
7. Quinolones
8. Thioamides
9. Cycloserine
10. PAS
• Standardized treatment of “routine” drug-susceptible TB
• 4 drugs, 6-9 months
• Safe, effective, inexpensive
• 95% cure, $20 (drug costs)
• Based on solid scientific evidence from ~ 30 years of drug discovery and controlled clinical trials, 1943-72
Second-Line Drugs and Treatment of Multidrug-Resistant TB
1. Isoniazid
2. Rifampicin
3. Pyrazinamide
4. Ethambutol
5. Aminoglycosides
6. Capreomycin
7. Quinolones
8. Ethionamide
9. Cycloserine
10. PAS
• Treatment based on laboratory drug-resistance testing and epidemiology information
• 4-6 drugs, 2 years
• Less effective, more toxic, expensive
• - 65%-75% cure
• - $3500 (drug costs)
• No clinical trials evidence to guide treatment or prevention
Drug Susceptible Multidrug
resistance
Extensive drug resistance
Isoniazid Isoniazid Isoniazid
Rifampicin Rifampicin Rifampicin
Pyrazinamide Pyrazinamide Pyrazinamide
Ethambutol Ethambutol Ethambutol
Aminoglycosides Aminoglycosides Aminoglycosides
Capreomycin Capreomycin Capreomycin
Quinolones Quinolones Quinolones
Thioamides Thioamides Thioamides
Cycloserine Cycloserine Cycloserine
PAS PAS PAS
Resistance by definition Resistance possible or likely
Extensive Drug Resistance Among MDR TB Isolates Submitted to 14 Supranational Reference Labs, by Region 2000–2004
Geographic Region Total MDR TB isolates (n)
XDR TBn ( % )
Industrialized nations
Latin America
Eastern Europe
Africa and Middle East
Asia
821
543
406
156
1,572
53 ( 6 )
32 ( 6 )
55 ( 14 )
1 ( <1 )
204 ( 13 )
Total 3,418 345 (10)
XDR TBAwareness and Emergency Response
• Oral and poster presentations at IUATLD conference, November 2005
• CDC report on Emergence of Mycobacterium tuberculosis with Extensive Resistance to Second-Line Drugs --- Worldwide, 2000--2004, March 24, 2006
• 16th International AIDS Conference presentation, August 2006
• Global alert issued by WHO on emerging threat of highly lethal strains of drug resistant TB (XDR TB) on September 5, 2006
• Emergency experts’ meeting (MRC, WHO, CDC) in Johannesburg, SA on September 7-8
• Call for Global XDR TB Task Force in Geneva, first meeting October 2006
XDR TB in KwaZulu-Natal Province (KZN), South Africa
• Reports of high mortality from TB in ARV treatment program in KZN in 2005
• Team of collaborators invited to identify problem• Investigators preformed cross-sectional study of TB suspects
attending rural hospital• 1539 patient isolates, 544 diagnosed with M.tb
– Of these, 221 (41%) MDR TB– Of these, 53 (24%) XDR TB
» Of these patients, 26 had no h/o TB treatment; » 44 of 44 tested were HIV infected;» 52 (98%) died; 15 were on ARVs
• XDR TB now documented in 28 health care institutions throughout KNZ
Expert Consultation on Drug Resistant Tuberculosis
• Expert Consultation organized by Medical Research Council (MRC) to strategize steps forward in Southern Africa Development Community (SADC) countries to address problem of drug resistance, September 7-8, 2006
• Convened by Medical Research Council, Republic of South Africa (RSA) Department of Health
• Key stakeholders with experience in drug-resistant TB response – WHO, CDC (DTBE and RSA GAP), KNCV
• Representatives from all 9 provinces of RSA
• Representatives from 10 SADC countries
Expert Consultation 7-Point Plan: Short Term Response
“Improve function and performance of national TB programs to strengthen treatment adherence and achieve high rates of treatment completion for all TB patients”
• Develop national emergency response plan for MDR/XDR TB within 3 months
• Conduct rapid surveys of MDR TB and XDR TB within the next 3-6 months
• Strengthen and expand current national TB laboratory capacity
• Urgently implement broad infection control practices in health care facilities with special emphasis on those facilities providing care for PLWHA
7-Point Plan: Long Term Response
• Establish capacity for clinical public health managers to effectively respond to MDR/XDR TB
• Promote universal access to ARVs for all TB patients through collaboration with HIV/AIDS treatment and care programs
• Support an increase in research for anti-TB drug development and rapid diagnostic test development for MDR/XDR TB
XDR TB is a significant threat to the major gains made in global TB control.
World Health Organization
Individuals with TB, including XDR TB, are human beings with human rights. We must treat all people with TB with respect, preserve their dignity, and save their lives. There is no role for stigma and discrimination in managing TB.
Professor Gavin Churchyard
Director, Aurum Institute for Health Research
Critically important to take steps now to prevent further spread of highly- resistant TB.
MDR TB in 1990s signaled the beginning of a global epidemic
Ensure adequate treatment of both
drug-susceptible and drug-resistant TB o Ensure patients complete TB and
MDR TB treatment through DOTS programs
o Strengthen lab capacity for diagnosis of MDR TB and second-line drug susceptibility testing
o Use of quality-assured TB drugs Expand surveillance to determine
trends and better evaluate XDR TB
XDR TB
MMWR 3/24/06
First global report of highly drug resistant TB, which shows widespread presence of virtually untreatable TB
Survey of global network of supranational TB reference laboratories, consisting of top-
performing TB labs located on 6 continents 2% of the isolates (347 out of nearly 18,000) were identified w/ extensive drug resistance (MDR
TB that is also resistant to 3 of the 6 classes of second-line drugs that are used to treat TB) o XDR TB was ID-ed in all regions, but was most frequent in the countries of the former
Soviet Union and in Asia o While global trend data is limited, available data may indicate some increases in XDR
TB Because reference labs are more likely to receive data f/ complex TB cases, looked at population-level data from selected countries to further understand the prevalence of XDR TB and trends
o In U.S., found 4% of MDR TB cases were highly drug resistant – XDR cases increased slightly, but not significantly, f/ 3.9% of MDR cases in early 90s to 4.5% by end of 2004
o In Latvia, a country w/ one of the highest rates of MDR TB, 19% of MDR TB cases were highly drug resistant.
CDC is partnering to raise awareness and enhance strategies for
TB prevention worldwide
CDC is a member of the Green Light Committee, which was created to increase access
to quality-assured, lower cost second line drugs while ensuring their proper use to prevent increased drug resistance.
CDC is urging more accurate and rapid detection and treatment of drug-resistant TB, including the development of international standards for second line drug susceptibility testing, new anti-TB drug regimens, and better diagnostic testing
Must build capacity of frontline providers to diagnose and ensure completion of treatment, which will help avert drug resistance
Worsening drug resistance around the world poses a serious threat to our ability to treat & control TB Treating patients with drug-resistant TB is costly,
and drugs are toxic and expensive Because drug resistant TB requires 4-5 drugs to
treat, this level of resistance precludes effective treatment in many areas o While places with more resources, such as the
U.S. or Latvia, may have greater access to additional effective drugs, the majority of TB cases occur in places unlikely to have access
o Limited drugs mean that patients with XDR TB are virtually untreatable according to international TB treatment guidelines in most countries
Patients with drug-resistant TB have worse
treatment outcomes (death or treatment failure) o Compared to patients with MDR
TB, those with XDR TB were 64% more likely to die during treatment in the U.S.
o In Latvia, patients w/ XDR TB were 54% more likely to die or have tx failure
XDR TB Messages First global report of highly drug resistant TB, which shows
widespread presence of virtually untreatable TB
• Survey of global network of supranational TB reference laboratories, located on 6 continents
• 2% of the isolates (347 out of nearly 18,000) were identified w/ extensive drug resistance
• XDR TB was ID-ed in all regions, but was most frequent in the countries of the former Soviet Union and in Asia– While global trend data is limited, available data may
indicate some increases in XDR TB• In U.S., found 4% of MDR TB cases were highly drug
resistant • In Latvia, MDR TB, 19% of MDR TB cases were highly drug
resistant
XDR TB MessagesWorsening drug resistance around the world poses a serious
threat to our ability to treat & control TB
• Treating patients with drug-resistant TB is costly, and drugs are toxic and expensive
• Because drug resistant TB requires 4-5 drugs to treat, this level of resistance precludes effective treatment in many areas
• While places with more resources, such as the U.S. or Latvia, may have greater access to additional effective drugs, the majority of TB cases occur in places unlikely to have access
• Limited drugs mean that patients with XDR TB are virtually untreatable according to international TB treatment guidelines in most countries
XDR TB Messages Worsening drug resistance around the world poses a serious
threat to our ability to treat & control TB (2)
• Patients with drug-resistant TB have worse treatment outcomes (death or treatment failure)
• Compared to patients with MDR TB, those with XDR TB were 64% more likely to die during treatment in the U.S.
• In Latvia, patients w/ XDR TB were 54% more likely to die or have tx failure
• In KZN, 98% of patients with XDR TB and HIV infection died, despite adequate response to ARVs
XDR TB Messages Critically important to take steps now to prevent further spread
of highly-resistant TB
• MDR TB in 1990s signaled beginning of a global epidemic• Ensure adequate treatment of both drug-susceptible and drug-resistant
TB– Ensure patients complete TB and MDR TB treatment through DOTS
programs– Strengthen lab capacity for diagnosis of MDR TB and second-line
drug susceptibility testing– Use of quality-assured TB drugs
• Expand surveillance to determine trends and better evaluate XDR TB• Must have adequately functioning TB programs to address
problem• Implement broad infection control precautions• Additional resources (human and financial)
XDR TB MessagesCDC is partnering to raise awareness and enhance strategies
for TB prevention worldwide
• CDC is a member of the Green Light Committee, created to increase access to quality-assured, lower cost second line drugs while ensuring their proper use to prevent increased drug resistance
• CDC is urging more accurate and rapid detection and treatment of drug-resistant TB, including the development of international standards for second line drug susceptibility testing, new anti-TB drug regimens, and better diagnostic testing
• Must build capacity of frontline providers to diagnose and ensure completion of treatment, which will help avert drug resistance
XDR TB Messages CDC is partnering to raise awareness and enhance strategies
for TB prevention worldwide (2)
New messages
• Participation in expert consultation with WHO and MRC
• Consensus plan of action
• Strengthen the laboratory
• Train the health care workers
Media Quotes in U.S.:March 24, 2006
• Dr. Kenneth Castro, director of the CDC's division of TB elimination, said emergence of a super-resistant strain is a potent reminder that tuberculosis remains a formidable threat. "It is widely distributed geographically, including in the United States, and renders patients virtually untreatable," Castro said.
• Dr. Marcos Espinal, executive secretary of WHO's TB elimination program, called XDR TB a veritable death sentence. "If people are failing first- and second-line drugs and we don't have in the pipeline a new drug for immediate use, that's a crisis," he said.
XDR-TB WHO expresses concern
WHO background briefing note issued prior to XDR-TB Expert Consultation meeting in South Africa
XDR-TB Coverage from international broadcasters:
'Virtually untreatable' TB found A "virtually untreatable" form of TB has emerged, according to the World Health Organization (WHO). Extreme drug resistant TB (XDR TB) has been seen worldwide, including in the US, Eastern Europe and Africa, although Western Europe has had no cases. Dr Paul Nunn, from the WHO, said a failure to correctly
implement treatment strategies was to blame.
XDR-TB Coverage in major weekly journals
Newsweek Sept. 13, 2006 –
WHO recently issued a warning that deadly new strains of tuberculosis appear to be spreading around the globe… HIV sufferers are particularly vulnerable because of their weakened immune systems. TB, already the world’s fourth most fatal infectious disease, could wreak havoc with AIDS treatment programs
XDR-TB African press coverage:
New TB strain in SA: 'No time to wait'07 September 2006 The extreme drug-resistant tuberculosis (XDR-TB) in KwaZulu-Natal must be dealt with urgently, international health experts said in Johannesburg on Thursday."There is no time to wait before we embark on decisive action," said the World Health Organisation's Dr Ernesto Jaramillo, explaining that an epidemic could have a deadly impact.
XDR-TBInternational headlines:
Deadly TB strain spreading across globe
Global alert over deadly new TB strains
Africa: "Extreme" TB Bug Prompts Calls for Rapid Action
South Africa: Action plan developed to combat drug resistant TB
TB strain with extreme resistance to drugs creates nightmare scenario
WHO urges South Africa to curb TB killer super-bug
TB experts will grapple with deadly new strains: WHO
Experts call for urgent steps to battle virulent TB strain
XDR-TB Editorial in New York Times & Int. Herald Tribune
EXTREME TUBERCULOSIS SEPTEMBER 14, 2006
TB is outrunning us. In the last few months, 53 patients in the South African province of KwaZulu-Natal were found to have a form of the disease resistant to enough existing drugs that it is virtually incurable. All but one of those patients have died…
Stinginess created this problem. Generosity is needed to fix it.
Stop TB XDR Response
1. Coordination – Develop an appropriate, coordinated global response to XDR TB
2. Resource mobilization – Raise sufficient funds to ensure no delays in the global response to XDR TB
3. Case definitions – Ensure consistency in surveillance and case management
4. Monitoring and evaluation – Determine geographical and temporal spread of XDR TB
Stop TB XDR Response (2)
5. Communications – Provide a proactive flow of information to all stakeholders, including member states and the global media
6. Case management – Define the optimal way of rapidly identifying suspect XDR cases and ensuring appropriate treatment; determine appropriate infection control measures in health facilities
7. Country support – Ensure a timely and sufficient response to requests from countries for assistance
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